F l e x o r Tend o n In j u r i e s

Jin Bo Tang, MD

KEYWORDS
 Flexor tendon  Repair methods  Pulley release or venting  Early active motion
 Secondary surgeries

KEY POINTS
 Zone 2 flexor tendon repairs have evolved greatly over the past 3 decades.
 The key developments in zone 2 repairs are (1) use of strong core suture, typically 4- or 6-strand
repairs, (2) venting the critical annular pulley judiciously to avoid compression to the repaired
tendon, (3) ensuring slightly tensional repair to prevent gapping at the repair site, (4) performing
a digital extension-flexion test to ascertain quality surgical repair, and (5) early partial range active
motion to ensure tendon gliding but not overloading the repair site.
 I prefer direct repair of the very distal flexor tendon or in making the distal junction of the grafted
tendon. In zone 2 and proximal zone 1, I use a 6-strand repair method, the M-Tang repair, in repair-
ing the flexor tendons.
 A few recent evolutions have been reported by surgeons, which hold promise to be adopted by
other hand surgeons: (1) using a strong core suture-only repair method, (2) venting the A3 together
with A4 pulleys in case of need to sacrifice clinically insignificant tendon bowstringing for gain of
range of active motion of the finger, and (3) a wide-awake surgical setting for tendon repair or te-
nolysis.

INTRODUCTION Judicious venting of the critical annular pulley

Ensuring that a slight tension is created by the
Several recent articles have evaluated develop- repair to prevent gapping
ments in flexor tendon repair and their contribution Performing digital extension-flexion tests to
to progress toward reliable primary repair of the confirm the quality of the surgical repair
flexor tendons.1–5 This article highlights the rele- Early partial range active motion to ensure
vant anatomic and mechanical features, clinical tendon gliding without overloading the repair
methods, and essential elements in a reliable
repair, then offers an overview of advancements Having the patient wide awake without use of a
in flexor tendon repair. tourniquet during surgery represents an important
Zone 2 flexor tendon repairs have evolved advancement, allowing active motion of the
greatly over the past 3 decades, and conse- tendon during surgery.11,12 Wide-awake surgery
quently, outcomes have changed dramatically has also transformed how tenolysis and secondary
since the last half of the twentieth century. Several tendon reconstruction are performed.
major conceptual changes, and widespread use of
some key surgical methods and postoperative ANATOMIC AND MECHANICAL KEY POINTS
motion protocols have helped to bring about the
changes.6–17 Current key practices include A unique feature of the flexor tendon anatomy is
plasticsurgery.theclinics.com

the presence of segmental annular pulleys in the

Using strong core sutures, typically 4- or digital area, with the A2 pulley over the proximal
6-strand repairs two-thirds of the proximal phalanx being the

Disclosure Statement: The author has nothing to disclose.

Department of Hand Surgery, The Hand Surgery Research Center, Affiliated Hospital of Nantong University, 20
West Temple Road, Nantong 226001, Jiangsu, China
E-mail address: [email protected]

Clin Plastic Surg 46 (2019) 295–306

https://doi.org/10.1016/j.cps.2019.02.003
0094-1298/19/Ó 2019 Elsevier Inc. All rights reserved.
296 Tang

largest and strongest, and the A4 pulley over the The diameter of suture locks in the tendons—a
midpoint of the middle phalanx being the second small diameter of locks diminishes anchor
largest (Fig. 1). The annular pulleys serve to pre- power
vent tendon bowstringing during digital flexion. The suture calibers (diameter)
Although the A3 and A1 pulleys also perform this The material properties of suture materials
function, their role is less critical than the A2 and The curvature of tendon gliding paths—the
A4. Loss of integrity of any one of the pulleys alone repair strength decreases as tendon curva-
has no marked functional consequence, although ture increases
anatomically, minor tendon bowstringing occurs The holding capacity of a tendon, affected by
at the site of the loss. varying degrees of trauma and post-
The middle and distal parts of the A2 pulley (1.5– traumatic tissue softening
1.7 cm long in adult middle finger) and the A4 pul-
ley (about 0.5 cm long) are the narrowest and most It must be realized that tendon curvature during
constricting to the flexor tendons. These sites finger flexion greatly affects the repair strength. A
become compressive to the repaired tendons tendon under curvilinear tension is subjected to
because of postoperative tendon swelling. These linear pulling and bending forces. Therefore, a
narrow pulley sites may be incised to allow the repair in a tendon under a curvilinear load is
repaired tendons to glide more freely. weaker than that under a linear load; the repair
Several factors affect the strength of repaired strength decreases progressively as the curvature
tendon: increases.18,19 Therefore, the repair fails more
easily in the flexed finger, and when the finger
The number of suture strands across the repair moves to approach full flexion, a bent tendon is
sites—strength is roughly proportional to the particularly prone to fail. This is the mechanical ba-
number of core sutures sis of current partial active finger flexion protocols
The tension of repairs—most relevant to gap for- and 1 reason why a full fist should be avoided in
mation and stiffness of repairs the initial a few weeks after surgery (Table 1).
The core suture purchase Fig. 2 summarizes the breakdown of contribu-
The types of tendon-suture junction—locking or tors of postoperative resistance to tendon
grasping gliding20 that should be considered in planning

Fig. 1. Locations of the annular and cruciate pulleys of the fingers and the subdivisions of zone 1 and 2.
 Flexor Tendon Injuries 297

Table 1
of injury or a few days later. Primary repair indi-
Resistance to tendon gliding during active cates the end-to-end repair performed within
finger flexion in initial weeks of tendon 24 hours after tendon injury. When an experienced
healing surgeon is not available on the day of injury, the
repair can be deliberately delayed, and delayed
Resistance Healing Tendons primary repair is performed in a selective surgical
Active to Tendon during Active setting. The delay usually has no adverse effects
Flexion Gliding Motion on outcomes, but in this period of delay, antibiotic
None to Low Not easily use reduces the risk of infection of the wound.
mild disrupted Delayed primary repair is the repair performed
Mild to Low or Not easily within 3 or even 4 weeks after injury. The end-to-
moderate moderately disrupted end repair is often still possible 5 weeks after
high injury.
Moderate Very high Easy to disrupt; Zone 2 is the most complex and demanding and
to full should avoid will be highlighted in the following section.
such motion
Exposure and Finding Tendon Ends in Zone 2

and adjusting the active motion protocols. The The tendons are exposed through a Bruner skin
safety margin of early active digital flexion can be incision of 1.5 to 2 cm (Fig. 3), which is usually suf-
enhanced by a strong surgical tendon repair or ficient to expose the tendons. The author and col-
appropriately decompressing the tendon during leagues keep the skin incision as limited as
surgery through releasing restricting pulleys, possible to decrease edema of the digit and resis-
limiting the lengths of skin incisions, and mini- tance to tendon gliding after surgery. Retraction of
mizing the trauma to the tendon and sheath. After the proximal tendon stump is common, especially
surgery, delicate adjustments in early active in delayed primary repair. If the proximal flexor dig-
flexion to fit individual patients by a therapist or itorum profundus (FDP) tendon end has not
surgeon is also important. retracted far proximally, flexion of the metacarpo-
phalangeal (MCP) or proximal interphalangeal
PRIMARY AND DELAYED PRIMARY REPAIR (PIP) joints can bring the proximal end into the inci-
sion site.
Nowadays most lacerated flexor tendons in the If the proximal FDP tendon end retracts to the
hand and forearm are repaired on the same day palm, I do not extend the incision to the palm,

Fig. 2. The breakdown of contributors of postoperative resistance to tendon gliding. (A) Percentage contribution
to the resistance. (B) Contributing factors. (From Wu YF, Tang JB. Tendon healing, edema, and resistance to flexor
tendon gliding: clinical implications. Hand Clin 2013;29:167–78; with permission.)
298 Tang

Surgical Repair Techniques

The tendon tissue at the cut ends is often ragged
and should be conservatively trimmed with a scis-
sors. Basic requirements of a tendon repair in pri-
mary repair of a flexor tendon are sufficient
strength, smooth tendon gliding surface with fewer
suture exposures, prevention of gapping of the
repair site under tension, and easy to perform.
Different configurations of the repairs may pro-
duce good outcomes given all the requirements
are meet. Surgeons in different centers use
Fig. 3. A Bruner skin incision of 1.5 to 2 cm for expo- different multistrand repairs (Fig. 5).21 I use the
sure of the laceration site. 6-strand M-Tang repair method in the repair in
zone 2 (Fig. 6). I then add a simple running periph-
eral suture or add 3 or 4 separated stitches
but instead make an additional incision in the distal sparsely over the volar and lateral aspects of the
palm. I can always find the retracted tendon end in repair site with 6-0 nylon.
the distal palm. From this small incision, the prox-
imal tendon end is pushed distally within the syno-
Methods of End-to-End Repair: Keys
vial sheath bit by bit using 2 forceps (Fig. 4), like
pushing a rope until the distal end is seen out of There are 3 essential surgical keys of making a
the distal opening in the sheath. strong tendon repair. First, one must ensure core
The forceps instrument is used to pull the suture purchase of at least 0.7 to 1.0 cm to
exposed proximal end distally for about 1 cm. generate maximal holding power and a sufficiently
Then the finger is held in slight flexion; a 25-gauge large size (2 mm in diameter) of locks if a locking
needle is inserted at the base of the finger through suture is used. Surgical repair strength decreases
the proximal tendon stump to hold the tendon dur- as the length of the purchase decreases. Tendon
ing repair. cut surfaces tend to soften after trauma. The repair

Fig. 4. Pushing the retracted FDP tendon with 2 forceps through a distal palm incision.
 Flexor Tendon Injuries 299

A Fig. 5. Several multistrand core su-

ture methods used by hand sur-
geons. (A) A 4-strand repair. (B) A
8-strand repair. (C) A 6-strand repair
made from 3 groups (each in a
different color) of the Kessler repair
in asymmetric placement in 2 tendon
stumps.
B

is at great risk of rupture if the suture purchase is that results in 10% to 20% shortening of the
short. tendon parts encompassed by core sutures, or a
The second key in the repair is that certain ten- 20% to 30% increase in the diameter of junction
sion across repair site should be maintained. To site of the 2 tendon ends (Fig. 7).22 A small amount
prevent gapping, it is important to ensure the of baseline tension would counteract the tension
repair has tension or a certain degree of bulkiness of the flexor muscles during resting or active mo-
tion. The repair site becomes more flattened
once it is under the load of active digital flexion.
Such degrees of bulkiness do not hamper tendon
gliding with proper pulley venting.

Fig. 7. The appropriate tensioning of the repair site is

a key to preventing gap formation (A, B) during active
Fig. 6. The method of making a 6-strand M-Tang finger flexion. The recommended degree of bunching
repair, which the author uses for the FDP and PFL up is 20% to 30% (shown in C) increases in diameter
repair. of the tendons at the junction of the 2 tendon ends.
300 Tang

Finally, at least a 4-strand core suture is Performing Digital Extension-Flexion Test:

required; a 6-strand core suture is ideal. The Methods
caliber of suture used in adults is either 4-
After repairing the tendon and venting of pulleys,
0 or 3-0.
I always verify the quality of the repair and
Locking suture-junction in the tendon is not
adequate venting through a digital extension-
a must, although locking anchors are slightly
flexion test.14,22 The repaired finger is held at
more secure. If the locks are incorporated, the
full extension to confirm that no gaps are seen
locking circles of the suture in the tendon should
between the 2 cut ends. Next, the finger is
be of a sufficient size (approximately 2 mm in
moderately flexed to make sure the repaired
diameter).
tendon moves smoothly. Finally, the finger is
Peripheral sutures mainly serve to tidy up the
further pushed to marked flexion to confirm
repaired tendon stumps. Most surgeons now
that the repair site does not bunch against the
choose to insert only simple or sparse peripheral
pulleys and that venting of the pulley is
stitches. Some surgeons even do not supple-
adequate.
ment peripheral stitches when multistrand core
Under local anesthesia with sedation, brachial
sutures have been used.23,24 In the presence of
plexus blocks, or general anesthesia, the previ-
a strong multistrand core repair that has been
ously mentioned test is performed with the sur-
tensioned over the repair site, peripheral sutures
geon’s hand holding the repaired finger to obtain
become less important than previously thought.
passive finger motion. The wide-awake local anes-
I do not usually repair the flexor digitorum
thesia without a tourniquet approach offers a ma-
superficialis (FDS) tendon unless the FDS injury
jor advantage of the wide-awake surgery,25 as the
is partial or the wound is very clean. I do not
patient can actively move the tendon to ascertain
repair the FDS tendon during delayed primary
repair quality.
repair or if the injury is in the area of the A2 pulley
If gapping is found between tendon ends, the
(zone 2C).
repair is too loose and should be revised with
additional core or peripheral sutures. If the pul-
Venting of the Critical Pulleys ley is found to block smooth tendon gliding, it
should be further released. However, such addi-
It was previously believed that the A2 and A4 pul-
tional release should be progressive, 1 to 2 mm
leys were sacrosanct and should not be divided.
at a time, with repeated digital extension-flexion
One of the important improvements in tendon
tests, to ensure the release is just enough to let
repair in recent decades is the understanding
the repair site glide smoothly, rather than making
that clinically significant bowstringing does not
1 lengthy additional cut.
occur when the A2 pulley is released up to two-
thirds of its length and that the A4 pulley can be
entirely released, given the integrity of the other POSTOPERATIVE ACTIVE MOTION
critical pulleys.13,15 A part of the synovial sheath PROTOCOLS
including cruciate pulleys can be released
together with the annular pulleys. The method of I use a dorsal splint extending from the distal fore-
release is a longitudinal cut through the midline arm to the fingertips for postoperative protection.
with a scissors. Some other surgeons use an even shorter splint.16
However, no more than 1.5 to 2 cm total of the The exact wrist position is unimportant. The wrist
pulleys with the synovial sheath should be can be in neutral, mild flexion, or mild extension,
released.13 A pulley release does not need to be as long as the patient is comfortable. The splint
lengthy, because in the proximal part of a finger should be slightly flexed at the MCP joint, usually
of an average adult, the flexor tendons glide only for 30 to 40 , and be straight beyond this joint.
1.5 to 2 cm with full digital extension and flexion. The wrist position for splinting should avoid
This judicious pulley venting permits unimpeded marked flexion (which is uncomfortable) or marked
gliding of a strong but slightly bunched or edema- extension (which adds a lot of tension to the
tous tendon repair site during early active tendon repaired tendon).
motion after surgery. There is no need to start motion or therapy in the
I have observed that judicious venting or division first 3 or 4 days after surgery, which also avoids
of the A4 pulley does not lead to clinically signifi- pain and discomfort.1 From day 4 or 5, the patient
cant bowstringing, although anatomically there is should perform at least a few sessions of digital
minor tendon bowstringing that leads to no clinical motion exercises. In each session, to lessen resis-
consequence. The same is true of division of up to tance of joint stiffness, full passive finger motion—
two-thirds of the A2 pulley. usually 20 to 40 repetitions—should be performed
 Flexor Tendon Injuries 301

before active digital flexion. Then active digital MORE RECENT EVOLUTION OF METHODS
flexion should proceed gradually. In the first 3 to
4 weeks, only one-half to two-thirds active motion The major conceptual changes in repairing flexor
range should be the goal. Extreme digital flexion tendons are summarized in Table 2. Although
should be avoided, because marked finger flexion most of the advancements have already been dis-
would overload the repaired tendons, risking cussed, here I summarize the changes over the
repair disruption (Fig. 8). Most patients have last 5 to 6 years.
marked swelling at this time; a full range of active
motion of the operated finger is difficult to achieve. Placing the Knots Between the Two Tendon
Aiming for full active flexion of the finger is both un- Ends May Not Favor the Repair
necessary and unrealistic. However, full passive The modified Kessler repair was popular, but for
finger flexion and extension should always be per- zone 2 flexor tendon repair, this repair is now
formed to make the hand and finger as supple as seldom used. It has also been realized that the orig-
possible. inal Kessler repair with knots over the tendon sur-
From the end of week 3 or 4, a full range of face is actually slightly better than the modified
active flexion is the goal. Some patients who version in terms of preventing gapping.26 Most cur-
have difficulty with full active flexion at week 4 or rent multistrand repairs have knots over the tendon
5 may gradually achieve full flexion in later weeks. surface, and no adverse clinical consequences
However, exercise to reduce joint stiffness and have been noted with these repairs (Fig. 9). It is
prevent extension lag should always be performed now believed that placement of the knots between
for eventual recovery of active finger flexion. The tendon ends is not beneficial or unimportant.26–28
splint protection can be removed at the end of
week 5 or 6, but therapy usually should persist
for a few weeks to get rid of often seen remaining Asymmetric Suture Configurations May be
stiffness of the distal interphalangeal (DIP) joint, Preferable to Symmetric Designs
with or with nighttime splint protection. After Recent investigations have revealed that asym-
week 6, I sometimes urge patients to wear a splint metry in the configuration of sutures attaching
only when they go outside, which prevents unin- 2 tendon stumps is better than symmetric suture
tentional use or injury. placement.29,30 Asymmetric placement likely

A B

Fig. 8. Partial range active motion in the initial 2 to 3 weeks after surgery. Full fist or marked active finger flexion
should be avoided to prevent repair rupture. (A) Active flexion starts from full extension. (B) Active flexion upto
two-thirds of flexion arc is shown.
302 Tang

Table 2
The major conceptual changes in repairing flexor tendons over the past 3 decades

Subjects 1980s and 1990s 2010s

Surgical techniques
Tendon repair: zone 2 2-strand suture Multistrand suture (4 or 6 strands)
A2 pulley Should not be violated Can be partially vented if needed
A4 pulley Should not be violated Can be entirely vented if needed
Synovial sheath Closure recommended Do not need to repair the sheath
Suture purchase of repair Not been stressed Should be more than 0.7–1 cm
Tension across repair site Not been discussed An essential key of surgical repair
Extension-flexor test None A common quality check point
Wide-awake surgery Not incorporated A better approach of tendon repair
After surgery
Wrist position in protection Wrist flexion stressed Flexible, from mild flexion to extension
Starting motion within 4 d Common Unnecessary; no motion is better
Active flexion: first 2–3 weeks Not popular Popular
Avoid extreme flexion None A key to ensure safety of active flexion
Place-and-hold motion Popular Not a useful or efficient exercise
Out-of-splint motion None Advocated for reliable patients

favors gap resistance, and this design can be proposed originally, in particular, if such a release
found in some popular suture configurations. greatly favors gliding of the repaired tendon, and
the bowstringing caused by slightly extended
A Tensioned Slightly Bunched Repair is Better release is noticeable but still mild. This practice
Than a Flat Tension-Free Repair appears especially beneficial at the PIP joint
A flat, tension-free repair should be avoided. A area. Such extended release from the A4 to A3
tensioned slightly bunched repair favors gap resis- pulleys (including the sheath between them), if
tance and does not hamper tendon gliding as the needed, may favor tendon gliding at the cost of
narrow pulleys are released. mild bowstringing at the PIP joint, which actually
does not affect normal function of the
Slightly Extended Pulley Venting to Benefit finger.23,24,31–34
Finger Flexion Outweighs the Drawbacks of
Minor Tendon Bowstringing Peripheral Suture is Unnecessary When a
Strong Core Suture (a 6-Strand Repair) is Used
The author and colleagues tend to be conservative
in deciding the length of pulley release. The allow- This is a recent observation. A few surgeons have
able length may be slightly longer than what was reported not adding peripheral sutures when a

Fig. 9. A tendon repair showing most of the recognized points for making a reliable repair: sufficient lengths of
suture purchase, no knots between the tendon ends, tension across repair site, slightly bunching up at the junc-
tion of the 2 tendon ends, and asymmetry of the suture strands in 2 tendon ends.
 Flexor Tendon Injuries 303

strong 6-strand repair is made with tension; no OUTCOMES

repair ruptures were reported.23,24
When they followed an updated protocol, young or
junior hand surgeons were able to obtain reliably
Wide-Awake Surgery Allows Effective Testing
good outcomes with few or no repair ruptures.22
of Tendon Gliding
Surgeons from other units have reported zero rup-
This is a major development in flexor tendon tures in case series of more than 50 ten-
repair. With active participation by the patient dur- dons.23,38,39 Repair rupture appears to no longer
ing surgery, the extension-flexion test provides the be a major concern if all modern guidelines are
best validation of a successful repair. Surgeons carefully followed. Rupture occurs only in patients
can even educate the patient about postoperative who actively use the fingers in the first few weeks
motion during the procedure.34–37 after surgery, although there are rare instances
(estimated to be <1%) of unexplained ruptures of
Tendon-to-Bone Junction Can be Achieved ordinarily reliable repairs.22 However, although
Without Conventional Pull-Out Suture cases of tenolysis have dropped considerably,40
adhesions remain a concern, and severe tissue
As explained previously, a strong direct damage always poses the risk of developing
repair has replaced the pullout suture in my dense adhesions.
practice. The fact is that the terminal tendon
just proximal to its insertion to the distal phalanx
REPAIR IN OTHER ZONES AND THUMB
is distal to the DIP joint, which does not require
FLEXOR TENDONS
motion. Adhesions are allowed to develop
Zone 1
to help strengthen the repair. Therefore, as
much as possible, suture strands can be When the FDP tendon is cut in distal zone 1, pull-
used to achieve a strong and usually somewhat out sutures through the dorsal nail have been a
bulky repair, which favors both healing and common treatment, but I no longer use them. I pre-
strength. fer direct repair using several strong core sutures
(ie, up to 10 or 12-strand core suture repair). The
Limiting the Length of Incision Decreases direct repair connects the proximal stump to the
Gliding Resistance to the Tendon remnant of the distal stump and tissues such as
periosteum adjacent to the tendon insertion on
A surgical incision less than 2 cm long is recom-
the distal phalanx (Fig. 10). The methods of prox-
mended to allow exploration of the wound
imal zone 1 repairs and zone 2 are similar.
site and expose the tendon in the finger or
thumb. Such a short incision decreases postop- Zones 3, 4, and 5
erative edema and resistance to tendon gliding.
Making a lengthy Bruner incision increases The FDP tendons in zone 3 are repaired similarly
edema. If the tendon is retracted proximally to as in zone 2. The repairs are easier because of
the palm, an additional incision is made, rather lack of sheath over the tendon. The injuries in the
than extending the incision from the finger to carpal tunnel area (zone 4) are rare and are often
the palm. accompanied by lacerations in the median nerve
and arteries. The transverse carpal ligament has
Wrist Positioning is Unimportant, and a Short to be opened to facilitate repairs. Zone 5 injuries
Splint is Safe often involve multiple tendons with neurovascular
injury. Repair of the FDS and FDP tendons is
It is now understood that if the tendon repair is preferred, and early postoperative motion is
strong, the wrist does not have to be placed in advised.
a specific position. This allows considerable
freedom in wrist positioning. Thumb Flexor Tendon
The FPL tendon repairs follow the same methods
Out-of-Splint Exercise is Safe
of repairs of the FDP tendon in fingers. The surgi-
In my own practice, I have found out-of-splint mo- cal incision should usually be less than 2 cm. The
tion to be safe for compliant patients; in fact, it is oblique pulley has to be vented to allow perform-
actually more efficient. Splinting mainly serves to ing the repair. I use the 6-strand M-Tang repair
protect the patient from getting hurt or uninten- for all FPL tendons (Fig. 11).22,41 The proximal
tional hand use. For this reason, the splint should tendon frequently retracts into the thenar muscles,
be worn only between exercise sessions and at which can be retrieved through an incision in
night. thenar muscles or the carpal tunnel.
304 Tang

A B

Fig. 10. (A) The method of a strong direct repair for repairing the tendon cut at or close to tendon-bone insertion
of the finger. (B) An operative picture of this repair.

TENOLYSIS, PULLEYS, TENDON GRAFTING, SUMMARY OF ADVANCEMENTS FOR

AND STAGED RECONSTRUCTION ACHIEVING IDEAL REPAIR OUTCOMES
Tenolysis
Zone 2 flexor tendon repairs have evolved greatly
It is estimated that about 10% to 20% of the pa- over the past 3 decades, including several key
tients still need tenolysis after primary or delayed developments:
primary repair. Tenolysis is best performed in a
wide-awake setting without a tourniquet. The pa- Use of strong core sutures, typically 4- or
tient should move actively during the procedure 6-strand repairs
to demonstrate ample active tendon motion. I Judicious venting of the critical annular pulley
perform wide-awake tenolysis whenever possible. Ensuring that some tension is created by the
The patient is asked to forcefully flex the finger and repair to prevent gapping
wrist to break any remaining adhesions after surgi- Performing digital extension-flexion tests to
cal release of adhesions. confirm the quality of the surgical repair
Early partial-range active motion to ensure
Tendon Grafting and Staged Reconstruction tendon gliding without overloading the repair

Although I follow established methods and princi- Direct repair of the terminal FDP tendon or in
ples for these procedures, I use direct repair of the making the distal junction of the grafted tendon
grafted tendon to the residual stump of the distal is my preference. A few recent changes reported
FDP tendon when making a distal junction. For by surgeons hold the promise of wider adoption:
that purpose, I retain the distal stump for 1 cm
Using strong core-suture-only repair
(or slightly less) when removing the FDP tendons.
Venting the A3 together with A4 pulleys if greater
Starting the end of week 1 after surgery, I instruct
range of motion of the finger is needed
the patients to perform a full range of passive mo-
Using a wide-awake setting for tendon repair,
tion and less-aggressive active flexion of the finger
including grafting
that underwent surgery.

Fig. 11. The M-Tang repair for an FPL tendon cut. (A) After completion of repair, before taking the temporary
needle fixation away, the tendon is seen slightly bunched up. (B) After the needle fixation is taken away, the
tendon is flatter. No gapping was seen at thumb extension.
 Flexor Tendon Injuries 305

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